Should We Medicate Healthy Children to Fight Social Inequality?

June 09, 2016 • By Sebastian Sattler

It’s a statistic that seems almost unbelievable: the richest one percent now has more wealth than the rest of the world combined, according to an Oxfam report. Inequality exists between nations such as Great Britain and Sudan, within different social strata in countries such as the United States, and on lower levels of societal entities, like within the city of Chicago. Economic inequality diminishes the life chances of an incredibly high number of individuals with respect to nutrition, housing, health care, education and so on. In the long run, it can result in the implosion of social cohesion. The Oxfam report illustrates how the economic gap has grown in the last five years (see figure). The consequences of the social gap have an especially negative effect on poor children and may rob them of their open futures.

In a target article in one of the leading bioethics-journals, Baylor University’s Keisha Ray pessimistically states that society is unwilling to close this social gap through more funding for low-performing schools, better training and payment for teachers, or updating teaching resources. What if we instead provided poor children with pills that are believed to enhance their cognitive functioning, with the goal of helping them perform better at school? Ray proposes that providing healthy poor and disadvantaged children with stimulants that doctors usually prescribe for children with diseases (such as Attention Deficit Hyperactivity Disorder, ADHD) could enhance their opportunities.

Her proposal might be well-intentioned, but it is no solution to the problem of social inequality, as I argue in a comment written with Ilina Singh, Professor of Neuroscience at the University of Oxford. Literature reviews by Repantis or Ragan and their colleagues show that prescription stimulants such as methylphenidate and modafinil often fail to show substantive enhancing effects in healthy non-sleep-deprived individuals, and furthermore even impairments of cognitive functions are a possible result.

Notably missing are experiments outside the lab that show performance boosts, or studies systematically investigating side effects and long-term health consequences. Specifically important for the evaluation of Ray´s proposal is the fact that there have been no clinical trials to test the enhancement potentials of prescription stimulants in healthy children. Putting healthy children with their developing and vulnerable brains at risk of bearing the potential side effects can be seen as reckless, and it will therefore likely be difficult to get ethics approvals for such experiments in the near future.

But to endorse the use of such drugs in healthy children, they would have to be proven extremely safe and efficient, as argued by Gaucher and colleagues. This is also one reason why the authors of a position paper, supported by the American Academy of Neurology (AAN), Child Neurology Society (CNS), and the American Neurological Association (ANA) conclude that enhancement “in legally and developmentally nonautonomous children and adolescents without” diagnosed neurological disorders is not justifiable.

A literature review found that up to 9% of children of grade school- to high school-age and up to 35% of college-aged individuals already used prescriptions non-medically within one year, that is, they are abusing the medications they have been prescribed or gotten elsewhere. One consequence of such abuse could be that at least some of these individuals might attribute their educational success to the pills rather than to personal achievement and ability. Such attributions have been assumed to potentially cause reduced self-esteem and developmental autonomy.

Also, transforming Ray’s proposal to reality might make stimulant use among poor and disadvantaged children socially expected. They are already stigmatized in society, and this stigma might not be reduced if these children are labeled as needing stimulants to keep up with others. Moreover, if they still performed poorly while using stimulants—or if they refrain from using them—the stigma might increase, since they could be seen as hopeless cases.

Relatedly, politicians and other leaders might feel less pressure to take the long-term needs of poor and disadvantaged children seriously. Instead, a stimulant policy would be falsely expected to do the job of caring for these children, and perhaps even calming the social conscience.

Next, stimulant use among healthy, economically disadvantaged children might even motivate parents with sufficient economic resources to also give their children pills or shower them with less risky options such as private schools and classes to uphold their privileges, thus negating any “leveling of the playing field” the stimulants were meant to provide.

Moreover, if the pressure to use pills increases, parents or other gatekeepers might downplay, accept, or ignore side effects and exaggerate the medications’ efficacy. Thus, more children could be put at risk.

One unintended consequence of Ray´s proposal might be an escalation in the “arms race” in the educational system with more risks, more pressure, and more worries. This race might be beneficial for those who manufacture and sell the drugs - the pharmaceutical industry and pharmacies - but it is not beneficial for children and their families.

Thus, Ray puts the burdens of her solution to overcome policy failure and structural inequality on the shoulders of poor and disadvantaged children, while these children can hardly be seen as responsible for their situation. These burdens may weigh especially heavily on groups that have been structurally discriminated against for long periods of time, such as African Americans or Latinos in the United States.

Ray admits that stimulants are not magic pills that will update textbooks, decrease class sizes, or give teachers better training. But these are precisely the changes that—among others—are necessary to reduce social inequality. We therefore think that it is much more appropriate and necessary to fight for an investment of resources in schools and teachers. They can influence more poor and disadvantaged children in a more sustainable way, rather than applying a quick fix that not only targets one child at a time but can cause severe side effects and stigma in often long deprived social groups. Ray’s solution tackles the symptoms of a troubling social problem while allowing the roots of these inequalities to remain untouched.

We strongly agree with Ray that we have the duty to think about all potential means to create just conditions for children and for society in general to enable a sustainably enhanced quality of life. We disagree, however, on a fundamental point: for us, stimulants are no such means.